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BackgroundFor evaluation of breast cancer screening and informed prioritisation, it is important to examine the downstream healthcare use associated to participation. The objective of this study is to determine the healthcare use among breast cancer screening participants compared with screening-naïve controls.MethodsThe study is a register-based cohort study with 14 years of follow-up. We compare healthcare use among women who participated in the initial phase of the stepwise breast cancer screening implementation in Denmark (stratified on screening result: normal, false positive and breast cancer) compared with those invited in subsequent phases.ResultsScreening participants, especially those with false-positive results, tended to use primary healthcare services more than the screening-naïve group. Women with breast cancer and false positives received more breast imaging compared with the screening-naïve group. False positives consistently had the highest use of drugs compared with the control group. All screening groups had significantly higher use of outpatient clinic visits in the year of and following screening compared with the screening-naïve group. Screening groups were more likely to receive additional diagnoses in the years following screening than the screening-naïve group. There were no significant differences in medical procedures and days of hospitalisation.ConclusionsThe study highlights differences in primary healthcare use among screening groups compared with the screening-naïve group. Since use of primary care services is at the discretion of the women, this implies increased worries about health. Thus, these results indicate increased healthcare-seeking behaviour, especially among women with false-positive results.

AbstractObjectiveTo report on complications of conisation and its effects on fertility and stenosis.DesignRegister based nationwide cohort study on routinely collected data using several linked databases.SettingPrimary and secondary care in Denmark, 2006-18.PopulationThe conisation cohort comprised 48 048 conisations on women aged 23-65 who had undergone conisation within 120 days of a cervical biopsy. The biopsy cohort comprised 48 048 biopsies on women who had undergone a cervical biopsy but not conisation who were matched by age and time of procedure. Women were excluded from the conisation cohort before long term outcome analyses if they had undergone hysterectomy, resection of the uterus, or had cervical cancer or any long term outcomes within the 10 years before their conisation.Main outcome measuresBleeding, infection, and gynaecological operations within 30 days of conisation (stratified by age, year of conisation, and number of previous conisations) and long term risk of fertility treatment, fertility consultation, stenosis, cervical dilatation, infertility diagnoses, and death at any point after conisation. Long term outcomes were followed up until death, emigration, diagnosis of cervical cancer, hysterectomy or resection of uterus, or the end of 2018. Long term outcomes were analysed with incidence rate ratios from Cox regression models.ResultsBleeding, infection, and gynaecological operations were registered for 2.81% (n=1351), 0.48% (n=231), and 3.95% (n=1897) of all conisations within 30 days of the procedure, respectively. Women in the conisation cohort had increased risk of stenosis (incidence rate ratio 14.81, 95% confidence interval 7.55 to 29.05, 0.41% v 0.03% (n=176 v 12)) and cervical dilatation (2.68, 2.41 to 2.97, 4.01% v 1.58% (n=1735 v 668)) compared with women in the biopsy cohort. No significant differences were observed for the other outcomes when adjusting for baseline covariates (such as age and region of residence). Cervical suturing after bleeding was associated with a substantial increase in the risk of stenosis and cervical dilatation.ConclusionThis study found higher rates of complications within 30 days of conisation than previous studies with comparable outcome definitions, and a substantially increased risk of stenosis and cervical dilatation for women who had cervical suturing to treat bleeding after conisation. However, these results were based on few events in a small subgroup, and are therefore associated with major uncertainty. This study supports previous findings that conisation does not generally increase rates of infertility treatment or infertility diagnoses.

The degree of overdiagnosis in common cancer screening trials is uncertain due to inadequate design of trials, varying definition and methods used to estimate overdiagnosis. Therefore, we aimed to quantify the risk of overdiagnosis for the most widely implemented cancer screening programmes and assess the implications of design limitations and biases in cancer screening trials on the estimates of overdiagnosis by conducting an overview and re-analysis of systematic reviews of cancer screening. We searched PubMed and the Cochrane Library from their inception dates to November 29, 2021. Eligible studies included systematic reviews of randomised trials comparing cancer screening interventions to no screening, which reported cancer incidence for both trial arms. We extracted data on study characteristics, cancer incidence and assessed the risk of bias using the Cochrane Collaboration’s risk of bias tool. We included 19 trials described in 30 articles for review, reporting results for the following types of screening: mammography for breast cancer, chest X-ray or low-dose CT for lung cancer, alpha-foetoprotein and ultrasound for liver cancer, digital rectal examination, prostate-specific antigen, and transrectal ultrasound for prostate cancer, and CA-125 test and/or ultrasound for ovarian cancer. No trials on screening for melanoma were eligible. Only one trial (5%) had low risk in all bias domains, leading to a post-hoc meta-analysis, excluding trials with high risk of bias in critical domains, finding the extent of overdiagnosis ranged from 17% to 38% across cancer screening programmes. We conclude that there is a significant risk of overdiagnosis in the included randomised trials on cancer screening. We found that trials were generally not designed to estimate overdiagnosis and many trials had high risk of biases that may draw the estimates of overdiagnosis towards the null. In effect, the true extent of overdiagnosis due to cancer screening is likely underestimated. •Randomised cancer screening trials are rarely designed for estimating overdiagnosis.•Many trials were biased towards underestimating the degree of overdiagnosis.•Overdiagnosis was revealed in screening for lung, breast and prostate cancer.•The first overview and re-analysis of overdiagnosis in cancer screening trials.

To assess the comprehensiveness of the reporting of physical harms in colorectal cancer screening programmes (CRCSPs) in randomised controlled trials (RCTs) and systematic reviews (SRs). We conducted an overview of reviews, comparing the comprehensiveness of reporting of harms in SRs and RCTs with a recent SR conducted according to the PRISMA-harms extension, identifying 17 types of physical harm potentially resulting from CRCSPs. Proportion of the 17 types of physical harm reported per study (study coverage), across studies (outcome coverage) and the level of harm severity reported in RCTs and SRs. We identified 24 RCTs and 16 SRs investigating physical harms related to CRCSPs. The median study coverage was 4 and 3 out of the 17 types of harm, varying from 5.9-47.1% and 5.9-52.9% types of physical harm reported in RCTs and SRs, respectively. The median outcome coverage was 4 and 3 across RCTs and SRs, varying from 0-66.7% and 0-87.5% in RCTs and SRs, respectively. Of note, 4 types of harm were not reported in any of the identified SRs. Inconsistent definitions of harm in RCTs and SRs made it difficult to assess which levels of severity of harm that were reported in studies. Poor reporting of harms in RCTs was compounded in SRs. We found poor study and outcome coverage and considerable inconsistencies concerning how physical harms were defined in RCTs and SRs. The inconsistent reporting of harms may result in an underestimation of their magnitude in relation to CRCSPs, raising concerns about our current capacity to evaluate the safety of these programmes. Adequate use of existing guidelines for harm reporting in RCTs and SRs and international consensus on how best to define and measure harms in studies of CRCSPs is warranted.

Sarcopenia has recently been included in the international classification of diseases despite lack of evidence to support essential diagnostic aspects. Christoffer Bjerre Haase and colleagues argue that the change is a step towards overdiagnosis

ObjectiveTo compare the long-term psychosocial consequences of mammography screening among women with breast cancer, normal results and false-positive results.DesignA matched cohort study with follow-up of 12–14 years.SettingDenmark from 2004 to 2019.Participants1170 women who participated in the Danish mammography screening programme in 2004–2005.InterventionMammography screening for women aged 50–69 years.Outcome measuresWe assessed the psychosocial consequences with the Consequences Of Screening–Breast Cancer, a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions.ResultsAcross all 14 psychosocial outcomes, women with false-positive results averagely reported higher psychosocial consequences compared with women with normal findings. Mean differences were statistically insignificant except for the existential values scale: 0.61 (95% CI (0.15 to 1.06), p=0.009). Additionally, women with false-positive results and women diagnosed with breast cancer were affected in a dose–response manner, where women diagnosed with breast cancer were more affected than women with false-positive results.ConclusionOur study suggests that a false-positive mammogram is associated with increased psychosocial consequences 12–14 years after the screening. This study adds to the harms of mammography screening. The findings should be used to inform decision-making among the invited women and political and governmental decisions about mammography screening programmes.

To explore how trainee doctors in general practice navigate patient expectations and requests for non-indicated procedures or tests, and what factors may pressure them into practising defensively. A qualitative interview study with 13 GP trainees from the Capital Region and Region Zealand in Denmark. An interview guide was developed based on existing literature and a pilot interview with an experienced GP. Data were coded in NVivo (version 15) and analysed using thematic analysis. The trainees described several challenges when facing patient requests for unnecessary procedures or tests. These challenges were linked to their own uncertainty, patient expectations and behavior, as well as external factors. The trainees described experiencing self-doubt and uncertainty, particularly when their clinical judgement was questioned by patients. Managing patient expectations, especially when patients were worried, sought tangible evidence, or had private health insurance, was described as challenging. Additionally, clinical values and a stressful environment was said to further influence decision-making processes. Together, these factors sometimes pressured the trainees into adopting a more defensive approach. With more experience, many developed greater confidence and argumentation, making it easier to refuse patient requests while maintaining a good relationship. Our study indicates that uncertainty, patient expectations, and external circumstances may, in certain situations, pressure Danish GP trainees into practising defensively. Managing and navigating both their own and the patient's uncertainty emerges as a key challenge. Future research is needed to explore how trainees can be better supported and educated in managing uncertainty and patient expectations in general practice.

ObjectivesWe aimed to systematically identify and scrutinise published empirical evidence about overdiagnosis in malignant melanoma and examine how frequent overdiagnosis of melanoma is and whether this is related to different types of interventions or diagnostic technologies.Design and settingEmpirical studies that discussed overdiagnosis in malignant melanoma were eligible, including qualitative and quantitative studies in any type of population, age group and geographical location. We excluded studies that did not include empirical data, studies that only mentioned ‘overdiagnosis’ without addressing it further and studies that used the term overdiagnosis for cases of misdiagnosis or false positives.We developed the search strategy in cooperation with an information specialist. We searched five databases on 21 April 2022: MEDLINE, Embase, CINAHL, PsycINFO and Cochrane Library.This scoping review adheres to The JBI methodology and Prefered Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping reviews (PRISMA-ScR). Two reviewers independently screened titles, abstracts and full texts for inclusion and extracted data from the included studies. The data extracted include study characteristics, population details, research question, the context and the study’s main results.ResultsOur search resulted in 1134 potentially relevant studies. 35 studies were included: 29 register studies, 3 cohort studies, 1 case–control study, 1 survey study and 1 randomised controlled trial. Most register studies examined trends in melanoma incidence and/or mortality and found a significant increase in incidence between 0.39% and 6.6% annually and a little or no increase in mortality. Three cohort studies and one case–control study showed that skin screening was associated with increased detection of melanoma; especially in situ or thin invasive melanoma. Three studies estimated the degree of overdiagnosis which ranged from 29% to 60%.ConclusionsEpidemiological data suggest a high degree of overdiagnosis in malignant melanoma. Studies that examined the association between skin screening and malignant melanoma all found increased detection of melanomas, mostly thin and in situ melanomas, which raises concern about overdiagnosis.

Medical screening is a major driver of overdiagnosis, which should be considered when making an informed screening decision. Health professionals (HPs) often initiate screening and are therefore responsible for informing eligible screening participants about the benefits and harms of screening. However, little is known about HPs' knowledge of overdiagnosis and whether they are prepared to inform screening candidates about this risk and enable people to make an informed screening decision. This is a systematic review of studies examining HPs' knowledge and perception of overdiagnosis, whether it affects their position on offering screening, and their willingness to inform screening candidates about overdiagnosis. We conducted systematic searches in MEDLINE, Embase, Web of Science, Scopus, CINAHL, and PsycArticles without language restrictions. Two authors analysed the qualitative and quantitative data separately. Confidence in the findings of the qualitative data was assessed using the GRADE-CERQual approach. We included 23 publications after screening 9786 records. No studies directly examined HPs' knowledge of overdiagnosis. HPs' perceptions of overdiagnosis varied widely, from considering it a significant harm to seeing it as negligible. This seems linked to their overall beliefs about the benefits and harms of screening and to their position on offering screening, which varies from discouraging to actively promoting it. HPs also hold diverging approaches to informing screening candidates about overdiagnosis, from providing detailed explanations to limited or no information. There is a lack of research on HPs' knowledge of overdiagnosis, however, HPs who do know about overdiagnosis attribute substantially different levels of harm to it. This seems intertwined with their overall beliefs about the benefits of screening, their position towards offering screening, and their willingness to inform screening candidates about overdiagnosis. This has important implications for the public's right to evidence-based information and compromises an individual's right to make an informed screening decision.